USPSTF prostate cancer screening guidelines need emotion to resonate

USPSTF prostate cancer screening guidelines need emotion to resonateProstate cancer screening has always been controversial.

Now, with the USPSTF is recommending against screening for prostate cancer, gas is about to be poured on the proverbial fire.

Recently, the New York Times Magazine published a lengthy piece on the issue, perhaps not coincidentally, perfectly timed with the Task Force’s announcement.

In 2009, advocates for breast cancer screening were up in arms, with the Task Force recommending that mammograms for women between the ages of 40 and 49 were optional, and decision individually made between patients and providers.

This time, the recommendation against prostate cancer screening is more forceful, and is bound to not only be politicized, but attacked by specialists and prostate cancer survivors.

Prostate cancer screening is most commonly performed by a blood test testing for the prostate specific antigen, or PSA. But the test is not without its risks:

From 1986 through 2005, one million men received surgery, radiation therapy or both who would not have been treated without a P.S.A. test, according to the task force. Among them, at least 5,000 died soon after surgery and 10,000 to 70,000 suffered serious complications. Half had persistent blood in their semen, and 200,000 to 300,000 suffered impotence, incontinence or both. As a result of these complications, the man who developed the test, Dr. Richard J. Ablin, has called its widespread use a “public health disaster.”

I wrote in the New York Times earlier this year that Medicare should stop paying for PSA screening in men over the age of 75, mainly because PSA isn’t good enough to detect which prostate cancers are dangerous, or not.  There is no conclusive data showing PSA saves lives.

But statistics don’t resonate. In fact, prostate cancer screening supporters are already lining up in force to tell their inspiring stories of prostate cancer survival:

Advocates for those with prostate cancer promised to fight the recommendation. Baseball’s Joe Torre, the financier Michael Milken and Rudolph W. Giuliani, the former New York City mayor, are among tens of thousands of men who believe a P.S.A. test saved their lives.

To combat this, Task Force advocates will need to put a human face on the complications stemming from prostate cancer. Something like this:

[National Cancer Institute researcher Otis] Brawley tells the story of a patient who had surgery and then underwent radiation, which left him with severe damage to both his rectum and ureter. “He had every side effect known to man,” Brawley says. “He had a bag for urine, a bag for stool, he was a terrible mess, in and out of the hospital with infections.” The man died six years after his surgery, from an overwhelming infection. Yet cancer statistics would list such a man as a success story, Brawley says, “because he survived past the five-year mark.” Would an untreated prostate cancer have killed him within six years, too? There is simply no way to know.

Politicians and celebrities will use their poignant stories to powerfully attack the recommendations.  Evidence-based supporters will need more than cold terms like “number needed to treat” and “absolute risk reduction.”

Without stories of their own, the Task Force recommendations will be vilified in the arena of public opinion, despite having the studies on their side.  In today’s health care environment, emotion trumps data.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://twitter.com/GlassHospital John Schumann, M.D.

    Great point, Dr. Kevin. I applaud the USPSTF for making this ‘courageous’ recommendation, since that’s where the data leads them and that’s how I clinically feel about the utility of the PSA. It opens up that Pandora’s Box that most men, if fully informed, would not want to go down.

    Try telling that, however, to someone who’s been diagnosed and thinks that their has been saved.

    Last I checked, the American Cancer Society stats on prostate cancer survival was 100% @ 5 years. 100%!! I’d take those odds and forgo treatment.

    Here’s one of my most popular posts on the topic of what to do with indolent prostate cancer:

    http://glasshospital.com/2010/08/03/watchful-waiting/

    -Dr. John

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Well written and good points. Emotions and politics may once again over rule science and fact. 

  • http://laprp.com Arnon Krongrad, MD

    Despite having the studies on their side? Not so. Leaving aside the tangents of why a “draft” was published, why these non-clinicians left no room for nuance … and many other thorny issues, the fact is that the recommendation is based upon very poor science. 

    You can read more on the “New” Prostate Cancer InfoLink blog:http://prostatecancerinfolink.net/2011/10/08/poor-science-underlies-the-uspstf-recommendation-about-psa-based-screening

  • Anonymous

    My father lived five years and one month.

  • elizabeth52

    The problem with screening – it’s so hard to get unbiased information – there are so many vested and political interests in cancer screening. I went to the Nordic Cochrane Institute for balanced information on breast screening. I wanted to hear ALL of the evidence, not just the bits that support screening. I found an excellent overview that helped me make an informed decision to decline breast screening.
    I’ve found in cervical and breast cancer screening that we get a very one-sided and incomplete presentation of the research and facts – if I had relied on the “facts” provided by the screening authorities, I’d have been misled and certainly would not have been screening with informed consent.
    The attitude that all screening is mandatory and the best course of action for every individual is inappropriate – only one person can say screening is worth the risk – you. To make an informed decision though, we need all of the facts, not hype, spin, propaganda or scare campaigns.
    If screening leaves you in a dilemma, is it worthwhile? Women who are diagnosed with ductal carcinoma in situ often end up losing the breast and having chemo and/or radiation. Over-diagnosis is a serious and hidden risk in breast screening – most women die “with” DCIS, not “from” it. (some reports say 40% of older women have some DCIS)
    That’s not very comforting when you’re faced with a diagnosis of DCIS that “might” become invasive at some point in the future, but probably won’t…
    It’s similar to the dilemma with prostate cancer – so much of the cancer is indolent and will never bother you. Once something is discovered through screening though, many people are uncomfortable to “watch” a “cancer” over a few years or sit on a high reading/abnormal reading, even if it appears to be an indolent cancer or a false positive – it can be stressful and affect your quality of life.
    They’re difficult issues and that’s why we need to know about them “before” we screen, not suddenly presented with a problem with no easy answer.
    http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004720.pub2/abstract (A study on prostate screening from the Cochrane Library)

  • Michael Blackmore

    Questions about PSA are the hardest which I have ever had to address in over 30 years of practice in the UK NHS. 

    The problem is the screening test is unreliable, biopsy is unpleasant often associated with significant complications and uncertain in interpretation (and reportedly still misses over 20% of cancers) and in the end no one knows the best way to treat a positive biopsy (or even whether to treat it al all).

    I contrast this with cervical cytology (a safe and effective test which yields a readily interpretable result in most cases, the availability of a simple and effective treatment with insignificant associated morbity and a high proportion of good outcomes, simple and dicriminant follow up and the option of re-treatment for recurrence with equally low morbidity).How to advise?  I generally lay out the facts and the options backed up with some literature and see the patient again a few days (or more if they prefer) later to discuss the problem again and then arrange a specialist opinion having included the patient’s preferred option (at that stage) in the referral letter. 

  • Michael Blackmore

    Questions about PSA are the hardest which I have ever had to address in over 30 years of practice in the UK NHS. 

    The problem is the screening test is unreliable, biopsy is unpleasant often associated with significant complications and uncertain in interpretation (and reportedly still misses over 20% of cancers) and in the end no one knows the best way to treat a positive biopsy (or even whether to treat it al all).

    I contrast this with cervical cytology (a safe and effective test which yields a readily interpretable result in most cases, the availability of a simple and effective treatment with insignificant associated morbity and a high proportion of good outcomes, simple and dicriminant follow up and the option of re-treatment for recurrence with equally low morbidity).How to advise?  I generally lay out the facts and the options backed up with some literature and see the patient again a few days (or more if they prefer) later to discuss the problem again and then arrange a specialist opinion having included the patient’s preferred option (at that stage) in the referral letter. 

    • http://pulse.yahoo.com/_GZU3UCCZMHRYMTPEYW55MFEWGM Niki Payne

      “The problem is the screening test is unreliable, biopsy is unpleasant often associated with significant complications and uncertain in interpretation (and reportedly still misses over 20% of cancers)”……
      “I contrast this with cervical cytology” .
      As a WOMAN I beg to differ.  The cervical screening test is also unreliable, biopsy EXTREMELY unpleasant and it also is asscociated with siginificant complications -cervcial stenosis and an incompeteant cervix.
      “…a safe and effective test which yields a readily interpretable result in most cases ”  you mean “well it’s abnormal but we don’t know whether it will progress to cancer or not. We better test again in a few months or do a biopsy or  a colposcopy or something because we don’t know  what is causing the abnormal result.”Is that the interpretation you are talking about?

      Please treat your female patients with the same empathy and respect that you treat your male patients.

    • Anonymous

      I agree with Niki.
      The pap test is intrinsically unreliable, they even have a category for, “no idea, take a guess” (ASCUS).
      This testing cannot identify the few rare cases that will progress to invasive cancer and the majority that won’t – so everyone gets “treated”.
      My main concern with pap testing is the lack of respect for informed consent – many women are just pushed into screening or assume they must test. VERY few women benefit from pap testing, while huge numbers are left worried sick after false positives or harmed to some degree by over-treatment.

      The cancer has a lifetime risk of 0.65%, while the referral rate is a whopping 77% here in Australia…it’s been known for years that simply getting a false positive causes high anxiety and fear, while over-treatment and unnecessary biopsies can lead to cervical stenosis and cervical incompetence – this can mean infertility, premature babies and more c-sections. (plus psych issues) This massive over-treatment is so often swept away by doctors or dismissed as “minor”…

      I know many women who’ve endured these procedures after false positives and I can assure you they certainly didn’t regard these things as minor. My younger sister had an unnecessary cone biopsy after a false positive pap test – it was a devastating experience. Doctors need to remember these tests and procedures are on a very private part of our body – some doctors have a cavalier disregard for the dignity, bodily privacy and autonomy of women…not to mention the fear, anxiety, pain, suffering and harm caused to lots of healthy women….the more than 99% who can never benefit from testing.
      It disappoints me when some doctors praise pap testing with not one shred of regard for the huge numbers of women negatively affected by this unreliable test. So much damage to screen for a rare cancer. There is no doubt in my mind that far more women are harmed by this testing, than could possibly be helped…and all with no informed consent.

  • Anonymous

    Dr. Otis Brawley, chief medical officer of the American Cancer Society:

    “If your income is dependent on you not understanding something, it is very easy not to understand something.”

    • http://laprp.com Arnon Krongrad, MD

      Yet because two wrongs don’t make a right, the science is still lousy.

      The piece linked above was written by an author with no conflict of interest. Dr. Brawley and anyone else with an interest in the actual substance is invited to read and comment.

  • Joe Kosterich

    Good piece Kevin. Hopefully if we keep pushing facts then eventually that will win out over hype

  • http://arnonkrongrad.com Arnon Krongrad, MD

    Orwell would be proud of the USPSTF, to whom “public” means private. http://nyti.ms/vgxCop 

    If this is how the USPSTF handles simple communication, how can it possibly handle the subtlety of bedside medicine for which, on the basis of garbage science, it issues absolutist recommendations? As oncologist Dr. Raghavan recently asked: Do we need the USPSTF? http://bit.ly/sEG3j8

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